Provider Demographics
NPI:1518274455
Name:KATHLEEN WILSON MD PA
Entity Type:Organization
Organization Name:KATHLEEN WILSON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:W
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-537-0276
Mailing Address - Street 1:24600 S TAMIAMI TRL
Mailing Address - Street 2:SUITE 212 BOX# 308
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-7022
Mailing Address - Country:US
Mailing Address - Phone:239-495-0439
Mailing Address - Fax:239-495-2688
Practice Address - Street 1:24810 BURNT PINE DR
Practice Address - Street 2:SUITE 3
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-1973
Practice Address - Country:US
Practice Address - Phone:239-495-0439
Practice Address - Fax:239-495-2688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-13
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DS386AMedicare PIN